European Journal of Epidemiology

, Volume 28, Issue 5, pp 361–372

Healthy lifestyle behaviors and decreased risk of mortality in a large prospective study of U.S. women and men

  • Gundula Behrens
  • Beate Fischer
  • Simone Kohler
  • Yikyung Park
  • Albert R. Hollenbeck
  • Michael F. Leitzmann


Adiposity, insufficient physical activity, cigarette smoking, and poor diet have all been related independently to increased chronic disease risk, but their joint impact on overall health remains unclear. In a cohort of 170,672 women and men aged 51–71 years at baseline in 1996/1997 and followed-up through 2009, we investigated the individual and joint impact of four low-risk lifestyle factors: abdominal leanness (waist circumference <88 cm in women and <102 cm in men); recommended physical activity level (30 min or more of moderate exercise at least 5 times per week or 20 min or more of vigorous exercise at least 3 times per week); long-term non-smoking (never-smoker or quit smoking more than 10 years ago); and healthy diet (Mediterranean diet score within the upper two sex-specific quintiles). During 2,126,089 person-years of follow-up, 20,903 participants died. In multivariate Cox models, statistically significant decreased risks of mortality were observed for the low-risk factors abdominal leanness (relative risk (RR) = 0.86; 95 % confidence interval (CI) = 0.83–0.89), physical activity (RR = 0.86; 95 % CI = 0.84–0.89), non-smoking (RR = 0.43; 95 % CI = 0.42–0.45), and healthy diet (RR = 0.86; 95 % CI = 0.83–0.88). The larger the number of low-risk lifestyle factors, the lower was the mortality risk. The RR comparing adherence to all versus none of the factors was 0.27 (95 % CI = 0.25–0.29). We estimate that 33 % (95 % CI = 30–35 %) of deaths in our cohort were premature and could have been avoided if all study participants had adhered to all low-risk factors.


Waist circumference Physical activity Smoking Diet Lifestyle Mortality 


  1. 1.
    Allison DB, Downey M, Atkinson RL, Billington CJ, Bray GA, Eckel RH, et al. Obesity as a disease: a white paper on evidence and arguments commissioned by the Council of the Obesity Society. Obesity (Silver Spring). 2008;16(6):1161–77.CrossRefGoogle Scholar
  2. 2.
    Despres JP. Intra-abdominal obesity: an untreated risk factor for Type 2 diabetes and cardiovascular disease. J Endocrinol Invest. 2006;29(3 Suppl):77–82.PubMedGoogle Scholar
  3. 3.
    Li J, Siegrist J. Physical activity and risk of cardiovascular disease–a meta-analysis of prospective cohort studies. Int J Environ Res Public Health. 2012;9(2):391–407.PubMedCrossRefGoogle Scholar
  4. 4.
    McTiernan A. Mechanisms linking physical activity with cancer. Nat Rev Cancer. 2008;8(3):205–11.PubMedCrossRefGoogle Scholar
  5. 5.
    Alberg AJ. Cigarette smoking: health effects and control strategies. Drugs Today (Barc). 2008;44(12):895–904.CrossRefGoogle Scholar
  6. 6.
    Sofi F, Cesari F, Abbate R, Gensini GF, Casini A. Adherence to Mediterranean diet and health status: meta-analysis. BMJ. 2008;337:a1344.PubMedCrossRefGoogle Scholar
  7. 7.
    van Dam RM, Li T, Spiegelman D, Franco OH, Hu FB. Combined impact of lifestyle factors on mortality: prospective cohort study in US women. BMJ. 2008;337:a1440.PubMedCrossRefGoogle Scholar
  8. 8.
    Ford ES, Zhao G, Tsai J, Li C. Low-risk lifestyle behaviors and all-cause mortality: findings from the National Health and Nutrition Examination Survey III Mortality Study. Am J Public Health. 2011;101(10):1922–9.PubMedCrossRefGoogle Scholar
  9. 9.
    McCullough ML, Patel AV, Kushi LH, Patel R, Willett WC, Doyle C, et al. Following cancer prevention guidelines reduces risk of cancer, cardiovascular disease, and all-cause mortality. Cancer Epidemiol Biomarkers Prev. 2011;20(6):1089–97.PubMedCrossRefGoogle Scholar
  10. 10.
    King DE, Mainous AG 3rd, Geesey ME. Turning back the clock: adopting a healthy lifestyle in middle age. Am J Med. 2007;120(7):598–603.PubMedCrossRefGoogle Scholar
  11. 11.
    Byun W, Sieverdes JC, Sui X, Hooker SP, Lee CD, Church TS, et al. Effect of positive health factors and all-cause mortality in men. Med Sci Sports Exerc. 2010;42(9):1632–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Matheson EM, King DE, Everett CJ. Healthy lifestyle habits and mortality in overweight and obese individuals. J Am Board Fam Med. 2012;25(1):9–15.PubMedCrossRefGoogle Scholar
  13. 13.
    Knoops KT, de Groot LC, Kromhout D, Perrin AE, Moreiras-Varela O, Menotti A, et al. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project. JAMA. 2004;292(12):1433–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Khaw KT, Wareham N, Bingham S, Welch A, Luben R, Day N. Combined impact of health behaviours and mortality in men and women: the EPIC-Norfolk prospective population study. PLoS Med. 2008;5(1):e12.PubMedCrossRefGoogle Scholar
  15. 15.
    Iversen L, Hannaford PC, Lee AJ, Elliott AM, Fielding S. Impact of lifestyle in middle-aged women on mortality: evidence from the Royal College of General Practitioners’ Oral Contraception Study. Br J Gen Pract. 2010;60(577):563–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Kvaavik E, Batty GD, Ursin G, Huxley R, Gale CR. Influence of individual and combined health behaviors on total and cause-specific mortality in men and women: the United Kingdom health and lifestyle survey. Arch Intern Med. 2010;170(8):711–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Nothlings U, Ford ES, Kroger J, Boeing H. Lifestyle factors and mortality among adults with diabetes: findings from the European Prospective Investigation into Cancer and Nutrition-Potsdam study. J Diabetes. 2010;2(2):112–7.PubMedCrossRefGoogle Scholar
  18. 18.
    van den Brandt PA. The impact of a Mediterranean diet and healthy lifestyle on premature mortality in men and women. Am J Clin Nutr. 2011;94(3):913–20.PubMedCrossRefGoogle Scholar
  19. 19.
    Haveman-Nies A, de Groot L, Burema J, Cruz JA, Osler M, van Staveren WA. Dietary quality and lifestyle factors in relation to 10-year mortality in older Europeans: the SENECA study. Am J Epidemiol. 2002;156(10):962–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Hamer M, Bates CJ, Mishra GD. Multiple health behaviors and mortality risk in older adults. J Am Geriatr Soc. 2011;59(2):370–2.PubMedCrossRefGoogle Scholar
  21. 21.
    Gopinath B, Flood VM, Burlutsky G, Mitchell P. Combined influence of health behaviors on total and cause-specific mortality. Arch Intern Med. 2010;170(17):1605–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Nechuta SJ, Shu XO, Li HL, Yang G, Xiang YB, Cai H, et al. Combined impact of lifestyle-related factors on total and cause-specific mortality among Chinese women: prospective cohort study. PLoS Med. 2010;7(9):e1000339.PubMedCrossRefGoogle Scholar
  23. 23.
    Tamakoshi A, Tamakoshi K, Lin Y, Yagyu K, Kikuchi S. Healthy lifestyle and preventable death: findings from the Japan Collaborative Cohort (JACC) Study. Prev Med. 2009;48(5):486–92.PubMedCrossRefGoogle Scholar
  24. 24.
    Tsubono Y, Koizumi Y, Nakaya N, Fujita K, Takahashi H, Hozawa A, et al. Health practices and mortality in Japan: combined effects of smoking, drinking, walking and body mass index in the Miyagi Cohort Study. J Epidemiol. 2004;14(Suppl 1):S39–45.PubMedCrossRefGoogle Scholar
  25. 25.
    Yun JE, Won S, Kimm H, Jee SH. Effects of a combined lifestyle score on 10-year mortality in Korean men and women: a prospective cohort study. BMC Public Health. 2012;12:673.PubMedCrossRefGoogle Scholar
  26. 26.
    Loef M, Walach H. The combined effects of healthy lifestyle behaviors on all cause mortality: a systematic review and meta-analysis. Prev Med. 2012;55(3):163–70.PubMedCrossRefGoogle Scholar
  27. 27.
    Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539–58.PubMedCrossRefGoogle Scholar
  28. 28.
    Schatzkin A, Subar AF, Thompson FE, Harlan LC, Tangrea J, Hollenbeck AR, et al. Design and serendipity in establishing a large cohort with wide dietary intake distributions : the National Institutes of Health-American Association of Retired Persons Diet and Health Study. Am J Epidemiol. 2001;154(12):1119–25.PubMedCrossRefGoogle Scholar
  29. 29.
    Rimm EB, Stampfer MJ, Colditz GA, Chute CG, Litin LB, Willett WC. Validity of self-reported waist and hip circumferences in men and women. Epidemiology. 1990;1(6):466–73.PubMedCrossRefGoogle Scholar
  30. 30.
    World Health Organization. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser. 1995;854:1–452.Google Scholar
  31. 31.
    Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334–59.PubMedCrossRefGoogle Scholar
  32. 32.
    Marshall AL, Smith BJ, Bauman AE, Kaur S. Reliability and validity of a brief physical activity assessment for use by family doctors. Br J Sports Med. 2005;39(5):294–7.PubMedCrossRefGoogle Scholar
  33. 33.
    WHO. The world health report 2002: Reducing risks, promoting healthy life. Geneva: WHO; 2002.Google Scholar
  34. 34.
    Subar AF, Midthune D, Kulldorff M, Brown CC, Thompson FE, Kipnis V, et al. Evaluation of alternative approaches to assign nutrient values to food groups in food frequency questionnaires. Am J Epidemiol. 2000;152(3):279–86.PubMedCrossRefGoogle Scholar
  35. 35.
    United States Department of Agriculture. Design and Operation: The Continuing Survey of Food Intakes by Individuals and the Diet and Health Knowledge Survey, 1994-96. 1997. NFS Report No. 96–1.Google Scholar
  36. 36.
    Thompson FE, Kipnis V, Midthune D, Freedman LS, Carroll RJ, Subar AF, et al. Performance of a food-frequency questionnaire in the US NIH-AARP (National Institutes of Health-American Association of Retired Persons) Diet and Health Study. Public Health Nutr. 2008;11(2):183–95.PubMedCrossRefGoogle Scholar
  37. 37.
    Fung TT, McCullough ML, Newby PK, Manson JE, Meigs JB, Rifai N, et al. Diet-quality scores and plasma concentrations of markers of inflammation and endothelial dysfunction. Am J Clin Nutr. 2005;82(1):163–73.PubMedGoogle Scholar
  38. 38.
    Hill ME, Rosenwaike I. The Social Security Administration’s Death Master File: the completeness of death reporting at older ages. Soc Secur Bull. 2001;64(1):45–51.PubMedGoogle Scholar
  39. 39.
    Rich-Edwards JW, Corsano KA, Stampfer MJ. Test of the National Death Index and Equifax Nationwide Death Search. Am J Epidemiol. 1994;140(11):1016–9.PubMedGoogle Scholar
  40. 40.
    Schoenfeld DA. Partial residuals for the proportional hazards regression model. Biometrika. 1982;69(1):239–41.CrossRefGoogle Scholar
  41. 41.
    Greenland S. Variance estimators for attributable fraction estimates consistent in both large strata and sparse data. Stat Med. 1987;6(6):701–8.PubMedCrossRefGoogle Scholar
  42. 42.
    Lumley T. Analysis of Complex Survey Samples. J Stat Softw. 2004;9(8):1–19.Google Scholar
  43. 43.
    R Development Core Team. R: A Language and Environment for Statistical Computing. Vienna: R Foundation for Statistical Computing; 2011.Google Scholar
  44. 44.
    Costanzo S, Di Castelnuovo A, Donati MB, Iacoviello L, de Gaetano G. Wine, beer or spirit drinking in relation to fatal and non-fatal cardiovascular events: a meta-analysis. Eur J Epidemiol. 2011;26(11):833–50.PubMedCrossRefGoogle Scholar
  45. 45.
    Boffetta P, Hashibe M. Alcohol and cancer. Lancet Oncol. 2006;7(2):149–56.PubMedCrossRefGoogle Scholar
  46. 46.
    Glanz J, Grant B, Monteiro M, Tabakoff B. WHO/ISBRA Study on State and Trait Markers of Alcohol Use and Dependence: analysis of demographic, behavioral, physiologic, and drinking variables that contribute to dependence and seeking treatment. International Society on Biomedical Research on Alcoholism. Alcohol Clin Exp Res. 2002;26(7):1047–61.PubMedCrossRefGoogle Scholar
  47. 47.
    Leitzmann MF, Moore SC, Koster A, Harris TB, Park Y, Hollenbeck A, et al. Waist circumference as compared with body-mass index in predicting mortality from specific causes. PLoS One. 2011;6(4):e18582.PubMedCrossRefGoogle Scholar
  48. 48.
    Ford ES. The metabolic syndrome and mortality from cardiovascular disease and all-causes: findings from the National Health and Nutrition Examination Survey II Mortality Study. Atherosclerosis. 2004;173(2):309–14.PubMedCrossRefGoogle Scholar
  49. 49.
    Harrington M, Gibson S, Cottrell RC. A review and meta-analysis of the effect of weight loss on all-cause mortality risk. Nutr Res Rev. 2009;22(1):93–108.PubMedCrossRefGoogle Scholar
  50. 50.
    Wing RR. Physical activity in the treatment of the adulthood overweight and obesity: current evidence and research issues. Med Sci Sports Exerc. 1999;31(11 Suppl):S547–52.PubMedGoogle Scholar
  51. 51.
    Rosenthal M, Haskell WL, Solomon R, Widstrom A, Reaven GM. Demonstration of a relationship between level of physical training and insulin-stimulated glucose utilization in normal humans. Diabetes. 1983;32(5):408–11.PubMedCrossRefGoogle Scholar
  52. 52.
    Kasapis C, Thompson PD. The effects of physical activity on serum C-reactive protein and inflammatory markers: a systematic review. J Am Coll Cardiol. 2005;45(10):1563–9.PubMedCrossRefGoogle Scholar
  53. 53.
    Miyazaki H, Oh-ishi S, Ookawara T, Kizaki T, Toshinai K, Ha S, et al. Strenuous endurance training in humans reduces oxidative stress following exhausting exercise. Eur J Appl Physiol. 2001;84(1–2):1–6.PubMedCrossRefGoogle Scholar
  54. 54.
    Schnohr P, Scharling H, Jensen JS. Changes in leisure-time physical activity and risk of death: an observational study of 7,000 men and women. Am J Epidemiol. 2003;158(7):639–44.PubMedCrossRefGoogle Scholar
  55. 55.
    Kastorini CM, Milionis HJ, Esposito K, Giugliano D, Goudevenos JA, Panagiotakos DB. The effect of Mediterranean diet on metabolic syndrome and its components: a meta-analysis of 50 studies and 534,906 individuals. J Am Coll Cardiol. 2011;57(11):1299–313.PubMedCrossRefGoogle Scholar
  56. 56.
    Willett WC. The Mediterranean diet: science and practice. Public Health Nutr. 2006;9(1A):105–10.PubMedCrossRefGoogle Scholar
  57. 57.
    Rostron B. Smoking-Attributable Mortality by Cause in the United States: Revising the CDC’s Data and Estimates. Nicotine Tob Res. 2013;15(1):238–46.Google Scholar
  58. 58.
    Hang B. Formation and repair of tobacco carcinogen-derived bulky DNA adducts. J Nucleic Acids. 2010;2010:709521.PubMedCrossRefGoogle Scholar
  59. 59.
    Lee J, Taneja V, Vassallo R. Cigarette smoking and inflammation: cellular and molecular mechanisms. J Dent Res. 2012;91(2):142–9.PubMedCrossRefGoogle Scholar
  60. 60.
    Gandini S, Botteri E, Iodice S, Boniol M, Lowenfels AB, Maisonneuve P, et al. Tobacco smoking and cancer: a meta-analysis. Int J Cancer. 2008;122(1):155–64.PubMedCrossRefGoogle Scholar
  61. 61.
    Erhardt L. Cigarette smoking: an undertreated risk factor for cardiovascular disease. Atherosclerosis. 2009;205(1):23–32.PubMedCrossRefGoogle Scholar
  62. 62.
    Forey BA, Thornton AJ, Lee PN. Systematic review with meta-analysis of the epidemiological evidence relating smoking to COPD, chronic bronchitis and emphysema. BMC Pulm Med. 2011;11:36.PubMedCrossRefGoogle Scholar
  63. 63.
    Parsons A, Daley A, Begh R, Aveyard P. Influence of smoking cessation after diagnosis of early stage lung cancer on prognosis: systematic review of observational studies with meta-analysis. BMJ. 2010;340:b5569.PubMedCrossRefGoogle Scholar
  64. 64.
    Godtfredsen NS, Prescott E. Benefits of smoking cessation with focus on cardiovascular and respiratory comorbidities. Clin Respir J. 2011;5(4):187–94.PubMedCrossRefGoogle Scholar
  65. 65.
    Shavelle RM, Paculdo DR, Strauss DJ, Kush SJ. Smoking habit and mortality: a meta-analysis. J Insur Med. 2008;40(3–4):170–8.PubMedGoogle Scholar
  66. 66.
    Gellert C, Schottker B, Brenner H. Smoking and all-cause mortality in older people: systematic review and meta-analysis. Arch Intern Med. 2012;172(11):837–44.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2013

Authors and Affiliations

  • Gundula Behrens
    • 1
  • Beate Fischer
    • 1
  • Simone Kohler
    • 1
  • Yikyung Park
    • 2
  • Albert R. Hollenbeck
    • 3
  • Michael F. Leitzmann
    • 1
  1. 1.Department of Epidemiology and Preventive MedicineRegensburg University Medical CenterRegensburgGermany
  2. 2.Division of Cancer Epidemiology and Genetics, Department of Health and Human Services, National Cancer InstituteNational Institutes of HealthBethesdaUSA
  3. 3.AARPWashingtonUSA

Personalised recommendations